The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

Effects of social determinants on children's health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol

INTRODUCTION

Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0-4 years old (ie, under-fives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens.

METHODS AND ANALYSIS

The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys.

ETHICS AND DISSEMINATION

The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely available.

Economics of healthcare access in low-income and middle-income countries: a protocol for a scoping review of the economic impacts of seeking healthcare on slum-dwellers compared with other city residents

INTRODUCTION

People living in slums face several challenges to access healthcare. Scarce and low-quality public health facilities are common problems in these communities. Costs and prevalence of catastrophic health expenditures (CHE) have also been reported as high in studies conducted in slums in developing countries and those suffering from chronic conditions and the poorest households seem to be more vulnerable to financial hardship. The COVID-19 pandemic may be aggravating the economic impact on the extremely vulnerable population living in slums due to the long-term consequences of the disease. The objective of this review is to report the economic impact of seeking healthcare on slum-dwellers in terms of costs and CHE. We will compare the economic impact on slum-dwellers with other city residents.

METHODS AND ANALYSIS

This scoping review adopts the framework suggested by Arksey and O'Malley. The review is part of the accountability and responsiveness of slum-dwellers (ARISE) research consortium, which aims to enhance accountability to improve the health and well-being of marginalised populations living in slums in India, Bangladesh, Sierra Leone and Kenya. Costs of accessing healthcare will be updated to 2020 prices using the inflation rates reported by the International Monetary Fund. Costs will be presented in International Dollars by using purchase power parity. The prevalence of CHE will also be reported.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews. We will disseminate our results alongside the events organised by the ARISE consortium and international conferences. The final manuscript will be submitted to an open-access international journal. Registration number at the Research Registry: reviewregistry947.

Hydronephrosis severity score: an objective assessment of hydronephrosis severity in children-a preliminary report

The main challenge in the management of antenatally diagnosed hydronephrosis and ureteropelvic junction obstruction (UPJO) is to differentiate the one that is likely to resolve from the pathological one. In this study, a new hydronephrosis severity score (HSS), combining ultrasonographic and renographic parameters, has been developed. Hydronephrosis severity score was analyzed with regard to its usefulness in assessing the severity of UPJO, postoperative resolution, and interobserver reliability.

METHODS

Hydronephrosis severity score was devised with three parameters: differential renal function (DRF), drainage curve pattern, and ultrasonogram grade (Table 1). Hydronephrosis severity score ranges were divided as 0-4, mild; 5-8, moderate; and 9-12, severe and compared with clinical outcomes (resolution, persistence, or surgical intervention) by retrospective case record review of children with unilateral UPJO. Among those who underwent surgery, surgical outcomes were compared with changes in HSS at 6-month follow-up. Hydronephrosis severity score was computed by three observers, and interobserver variability was calculated.

RESULTS

A total of 125 case records (male:female = 93:32; right:left = 44:81) were analyzed. Among the patients analyzed, none (0/59) with HSS 0-4 warranted surgery, whereas 1 of 35 patients with HSS 5-8 underwent surgery, and all (31/31) with HSS 9-12 underwent surgery (P = 0.001). Overall, hydronephrosis resolved in 65, persisted in 28, and required surgery in 32 patients. Mean (standard deviation) HSS was 2.1 (0.75) in whom it resolved, 6.2 (0.78) in whom it persisted, and 10.2 (0.79) in those who underwent surgery (analysis of variance P = 0.001). Among those who underwent surgery, a better recovery of HSS was noted in younger infants (aged 2-5 months) with higher pre-operative DRF. There was 94.4% median agreement between radiologists and the surgeon (kappa 0.851), indicating a very good interobserver agreement.

DISCUSSION

Loss of DRF on progressive renograms remains the accepted criterion of significant UPJO although the lost function does not always recover after pyeloplasty. Newer scoring systems keep evolving to predict the need for surgery as well as assess resolution of UPJO, and the study's preliminary report suggests that HSS could turn out to be one such useful tool. In this study, those who deteriorated were the ones with HSS ≥9. One can use this as a criterion and decide on intervention before DRF deterioration. Hydronephrosis severity score could also be applied as an objective parameter for quantifying improvement/deterioration after surgery and comparing outcomes across centers. The drawbacks of the present study are its small size and the retrospective nature. Further prospective studies are required to validate the usefulness of HSS.

Hepatic haemangioma of infancy: role of propranolol

A newborn girl with a haemangioma of the liver failed to respond to cortico-steroid therapy. Ultrasonic evidence of the haemangioma disappeared after 2 months of treatment with propranolol. Propranolol, a non-selective beta-blocker, is a promising therapy in the management of haemangiomas.